Back pain affects 40% of the population. Up to 20% of the population visit their family doctor requesting help with their back problem. Up to 30% of patients continue to complain of significant back pain at one year following the onset of their symptoms.
Although the majority of patients have minor sprains or strains which are self limiting, a significant number of patients go on to develop severe chronic mechanical lower back pain which is caused by inflammatory changes in the lumbar disc associated with degeneration.
Another group of patients with degenerative spine disease go on to develop degenerative spondylolisthesis and spinal stenosis. This is a narrowing of the spinal canal caused primarily by degenerative changes in the facet joint, combined with a loss of normal disc height and buckling of the ligamentum flavum.
Degeneration occurs in a spinal segment. The spinal segment consists of the lumbar disc anteriorly and two facet joints posteriorly. This is therefore called a three joint complex. Degenerative changes in the disc can lead to changes in the facet joint and vice versa. In patients with significant lumbar disc degeneration, the facet joints are also usually degenerate.
Pain occurs from all components of the three joint complex, including the facet joints and the disc. The facet joint is in fact a synovial joint and suffers from the problems that are known to affect other synovial joints in the body like the hip and the knee. The facet joint particularly contributes to degenerate spondylolisthesis and commonly occurs at levels where the facet joints are sagittally orientated, for example at the L4/5 level.
After failing all the conservative treatments available, a minority of patients with back pain or leg pain will go on to require surgical intervention. For patients with predominantly lower back pain who have a degenerative lumbar disc, some surgeon's consider the solution lies in removing the pain generator which is the disc and restoring normal loading across the disc by doing an inter-body stabilisation procedure.
The two types of inter-body stabilisation procedure currently available are an artificial disc replacement performed anteriorly and inter-body fusions performed anteriorly and/or posteriorly. These inter-body stabilisation procedures are often combined with decompression of the spinal canal and the nerve roots if there is nerve root impingement.
As far as inter-body fusions are concerned, there are two basic strategies that surgeons adopt. The first is to perform an anterior inter-body fusion combined with posterior stabilisation externally of the spinal canal. Anterior inter-body fusion on its own is still questioned because it does not provide a posterior tension band. An alternative strategy is a posterior lumbar inter-body fusion, where the entire inter-body fusion procedure is performed from behind and it is combined with neural decompression as well as removal of the degenerative facet joints. Posterior lumbar inter-body fusion also provides a posterior tension band. This strategy therefore deals with all three joint components which can generate possible pain at the disc level, including the lumbar disc, the neural structures and the facet joints.
When it comes to lumbar disc arthroplasty procedures, these are performed via an anterior lumbar approach. The disc is removed and an artificial lumbar disc is inserted into the space. This removes the pain generator and allows normal loading across the disc, as well as allowing some movement at this level. The advantage of this is to reduce the strains on the disc above and therefore reduce the chances of adjacent segment degeneration. Several studies have shown that adjacent segment degeneration can occur above a fused segment because of the increased loads being transmitted to this level.
One of the disadvantages of anterior lumbar arthroplasty is that the facet joints at this level continue to move and also continue to act as a pain generator. In addition, if there is any neural impingement, these symptoms can continue. The other disadvantage of anterior lumbar arthroplasty is that the majority of spine surgeons are not familiar with the anterior approach, and although complications are uncommon, they can be life and limb threatening when they do occur.
There is therefore a concern among researchers and the surgical community, that long term results of anterior lumbar disc arthroplasty may be compromised by progressive degeneration of the facet joint at the same level. In addition, after lumbar disc arthroplasty, several patients continue to complain of facet joint pain because of increased loads being placed on the facet joint as a result of the surgical procedure.
At present there is no posterior lumbar arthroplasty procedure available. It is therefore an aim of the present invention to provide an artificial lumbar disc that can be inserted posteriorly, thereby delivering the advantages of approaching the spine posteriorly and removing the disadvantages associated with approaching the spine anteriorly.
It is a further aim of the present invention to provide a facet joint replacement prosthesis.
It is a yet further aim of the present invention to provide a lumbar prosthetic system that deals with the painful disc, the neural impingement and the painful facet joints by providing a combination of a lumbar disc prosthesis and a facet joint prosthesis as a single unit.
It is a further aim of the present invention to provide an artificial disc prosthesis that utilises one or more of the features and advantages provided by the posteriorly inserted disc but which can be inserted anteriorly.
It is a yet further aim of the present invention to provide a prosthetic system that deals with the painful disc, the neural impingement and the painful facet joints by providing a combination of a disc prosthesis and a facet joint prosthesis as a single system that works together.